Claims data management for health plans
Your clearinghouse moves claims. Gaine makes them reconcile.
Claims data management, for a health plan, means every claim resolves to the right member, provider, location and contract in every system that touches it. Clearinghouses transmit claims and core administration adjudicates them. Neither keeps those records in agreement across your other systems, and that is where unreconciled claims come from. Gaine HDMP does that job.
Where Gaine sits
| System | Its job | Where Gaine fits |
|---|---|---|
| Clearinghouse | Transmits and edits claims between providers and the plan | Unchanged. Gaine takes no part in transmission |
| Core administration | Adjudicates and pays | Receives reconciled member, provider and contract changes, by connector or change file |
| Payment integrity | Reviews claims for fraud, waste and abuse | Runs on the resolved records Gaine supplies |
| Warehouse or lakehouse | Analysis and reporting | Receives the reconciled records one way |
| Gaine HDMP | Keeps the records every claim points to in agreement, and links each claim to them | |
What reconciled claims look like
- Each claim points to one member, one rendering and billing provider, one service location and one contract, all as they stood on the date of service.
- Duplicates and resubmissions are recognized across systems, so a claim is worked once.
- Every system holds the same answer, and each received only the change it needed, with the evidence.
Where did the claim stop?
A provider asks why a claim has not paid. The clearinghouse accepted it, so transmission was not the problem. Core administration pended it: the service location on the claim does not match the location core administration holds for that provider.
Gaine shows that credentialing received the new location three weeks earlier and core administration did not. Core administration receives that change, by connector or change file, and the claim can be adjudicated.
Illustrative.
The result, at one health plan
Claims spread across more than 20 systems, and hundreds of millions of dollars that would not reconcile. With Gaine HDMP: $300 million in unreconciled claims reconciled, and the claims backlog cleared. Read the case study →
How claims and changes move
- Claims in: from core administration, or loaded into your data lake by your own processes and read by Gaine through a data share, or by file.
- Changes out: Gaine has built direct API connectors for HealthRules Payer, Facets, QNXT and EZ-CAP. Other systems receive reconciled change files through your own change control, event notifications, or Gaine’s platform API.
- Analysis: your warehouse or lakehouse receives the reconciled records one way.
Questions
Is Gaine a clearinghouse?
No. A clearinghouse transmits and edits claims between providers and the plan. Gaine keeps the member, provider, location and contract records those claims point to in agreement across your systems, and links each claim to them. It does not transmit or adjudicate claims.
Does Gaine work with any clearinghouse?
Gaine takes no part in transmission, so the clearinghouse does not change. Gaine works with the records in your core administration and other systems.
Is Gaine an analytics platform?
No. Analysis stays in your warehouse or lakehouse, which Gaine feeds with reconciled records one way.
Related reading
More on claims data management
The records behind every claim
A claim is only as clean as the member, provider, location and contract it points to. Gaine resolves those records first, so every system gives the claim the same answer.
Explore →Unreconciled claims and resubmissions
Claims that cannot be matched wait, providers resubmit, and the backlog compounds. One health plan reconciled $300 million of them with Gaine HDMP and cleared its backlog.
Explore →